How to remove BE cancer: EMR or ESD? Expected outcome

Transcription

1 How to remove BE cancer: EMR or ESD? Expected outcome Presented by Horst Neuhaus Institution Dpt. of Gastroenterology Evangelisches Krankenhaus Düsseldorf, Germany

2 Indications for endoscopic resection Type of visible lesions Staging Grading Confirmed LGD, HGD Adenocarcinoma T1a NX G1-3 T1b (sm 1) NX G1,2 Suggestive for neoplasia

3 0-Is 0-Is 0-Is+IIc Selection of patients with early adenocarcinoma Endoscopic characteristics predictive for sm invasion Low risk 0-IIb 0-IIb+IIc 0-IIc High risk

4 Aims of endoscopic resection Resection of focal neoplastic lesions to - achieve complete removal - to provide specimen for accurate histology En-bloc resection - Resection in a single piece without fragmentation R0 resection - Lateral and vertical margins free of neoplasia Complete local remission - R0 - R0 vertical / R1 horizontal and 1 negative f/u endoscopy

5 EMR Pros - Technically easy and fast - Safe - Inexpensive - Well established for early BE neoplasia Cons - Frequent need for piecemeal resection - Risk of missing areas of advanced neoplasia - Recurrent neoplasia in 1/3 of the cases

6 EMR Cap technique AC pt1b (sm1), L0, V0, TCD=0, pnx, R0 (HM0, VM0) (G2)

7 EMR Ligation technique AC pt1a (m2) L0, V0, TCD=0, R1 (HM1, VM0) G1

8 EMR Focal EMR of early BE neoplasia Studies 9 EMR sessions En-bloc / R0 resection rarely reported Complete local remission 93 % - 99 % Recurrences 3 % - 30 % FU periods (months) Ell C, Gastro 2000; 118: May A, Eur J Gastroenterol Hepatol 2001; 14: Peters FP, GIE 2005; 61: Larghi A, GIE 2005;62:16-23 Behrens A, Endoscopy 2005; 37: Conio M, World J Gastroenterol 2005;11: Ell C, Gastrointest Endosc 2007; 65: 3 10 Pech O, Gut 2008; 57: Pouw RE, GIE 2011; 74:35-43

9 EMR Focal EMR of early BE adenocarcinoma Patients 1000 Complete response 96.3 % Major complications 1.5 % Metachronous / recurrent neoplasia 14.5 % Successful endoscopic re-treatment 82.1 % Long-term complete remission rate * 93.8 % * Mean FU: 57± 33 months Pech O, Gastro 2014; 146:652-60

10 EMR Focal EMR of early BE neoplasia + RFA of remaining BE Focal mac EMR scar RFA of remaining BE Complete BE eradication

11 EMR Focal EMR of early BE neoplasia + RFA of remaining BE European multicenter trial (EURO II) Patients 132 Complete remission Neoplasia 92 % Intestinal metaplasia 87 % Adverse events 19 % Recurrence * Neoplasia 4 % Intestinal metaplasia 8 % * Mean FU: 27 months Phoa KYN, Gut 2016; 65:555-62

12 ESD Pros - High rates of en-bloc and R0 resection - Precise histopathology - Well established for early esophageal SCC Cons - Technically demanding - Perforation rate of 5 % - Long procedural duration

13 ESD

14 ESD pt1a (m1), L0, V0, TCD=0, Nx, R1 (HM1, VM0), G1

15 ESD Early BE neoplasia: uncontrolled single center studies Neuhaus Kagemoto Probst Chevaux Patients Resection rates - en-bloc 90 % 100 % 95 % 90 % - R0 EAC/HGD 39 % 85 % 74 % 64 % CR of neoplasia 96 % 100 % 98 % 92 % Adverse events - Bleeding / Perf. 4 % 4 % 1 % 7 % - Stricture 0 15 % 12 % 60 % Neuhaus H, Endoscopy 2012; 44: Kagemoto K, GIE ; 80: Probst A, Endoscopy 2015; 47: Chevaux JP, Endoscopy 2015; 47:

16 ESD versus EMR Single center prospective RCT Enrollment of patients (11/2012 5/2014) Patients with BE HGIN / AC 137 Exclusion 97 ASA IV 2 Pre-treatment 16 Non-visible neoplasia 10 Flat lesion 13 Massive submucosal invasion 21 Multifocal lesions 24 Extension 50 % of the circumference 7 Incomplete histology 4 Inclusion 40 Terheggen G, Gut 2016, Jan 22 [Epub ahead of print]

17 ESD versus EMR Single center prospective RCT Patients characteristics ESD EMR P Patients M / F 16/4 16/4 ns Mean age (years) ± SD 64 ±12 65 ±11 ns Mean BE length circular (cm) 1.1± ±1.2 ns Mean BE length tongue (cm) 2.4 ± ±3.2 ns Mean dm of the lesion (mm) 16±7 14±6 Histology HGIN 5 4 ns AC ns Terheggen G, Gut 2016, Jan 22 [Epub ahead of print]

18 ESD versus EMR Single center prospective RCT Results ESD EMR P Patients Mean procedure time (min) Complete resection En-bloc resection R0 resection of HGIN/AC 10/17 2/ SAE Elective surgery 4 3 ns CR neoplasia 94 % 94 % 1.0 Recurrence * * Mean FU: 23.1±6,4 months Terheggen G, Gut 2016, Jan 22 [Epub ahead of print]

19 ESD Early BE adenocarcinoma: type 0 - Is BE AC: pt1b (sm1), L 1, V 0, TCD=2, N X, R0 (HM0, VM0), G2

20 ESD Early BE adenocarcinoma: recurrence in an EMR scar

21 How to remove BE cancer: EMR or ESD? Indications Focal neoplastic lesions with no signs of massive sm invasion Methods EMR is the method of choice and achieves high complete remission rates ESD should be considered in case of suspected sm invasion or recurrences after EMR Remaining IM should be ablated by RFA Prerequisites Precise preoperative diagnostic evaluation Expertise in techniques and management of complications Decision making in tumor boards Long-term follow-up